Patient Forms

Welcome To Burke Orthodontics Letter

download the pdf


Transfer In Policy

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Transfer Out Policy

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Records Release

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Confidential Health Form – Youth

(New patients should fill this out and bring to your office visit)

download the pdf


Confidential Health Form – Adult

(New patients should fill this form out and bring to office visit)

download the pdf


Informed Consent

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TMJ History

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HIPAA Letter

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©2015 Burke Orthodontics.

Huber Heights 5211 Waynetowne Ct Suite A Huber Heights, OH 45424 Phone 937-630-3280 Fax 937-236-5542
Centerville 55 North Main Street Centerville, OH 45459 Phone 937-630-3280 Fax 937-434-3680
Serving Families of Wright Patterson Air Force Base in Ohio (WPAFB) 45433, Fairborn OH 45324, BellBrook OH 45305, Kettering OH 45429, Dayton and the surrounding communities.